WhiteCoat

Expect It

image007A patient came in for evaluation of head congestion. As the nurse was getting his vital signs in the room, he asked her who the emergency physician was.
“Dr. WhiteCoat,” she replied.
He turned his head to the side and asked his wife over his shoulder “Is that the one?”
His wife answered “Yup.”
The nurse asked him if he had a problem with me in the past.
“Not unless you call some guy shoving his fist up your ass a problem.”
The nurse looked shocked.
“I came in here with abdominal pain and I threw up blood. This guy tells me he needs to ‘check my rectum for blood.’ Then he buries his arm in my ass up to the elbow. I could have told him there wasn’t any blood up there. He ain’t coming nowhere near me with a pair of gloves from now on.”

When the nurse relayed this story to me, I looked his old records up on the computer before going into the room. Four years ago he came in with abdominal pain and complained of pus in his stool. He ended up having a GI bleed, but no pus was ever found. So the rectal examination has scarred him for the past 4 years.

The nurse and I laughed for a minute about whether I should walk into the room with a gown, mask, gloves and a tube of KY Jelly.

Then I started thinking.

Not too long ago, another patient whom I evaluated for abdominal pain complained to our hospital administration that he was having “post traumatic stress” from the rectal examination I performed. He was afraid of interacting with men bigger than he was and could no longer stand in lines because he was afraid of what the people standing in line behind him might do.

It’s not like I have gorilla fingers. My finger is about 3 inches long and about 1.5 inches in circumference at its widest. Most formed stool is much longer and much wider than my finger, but I don’t know any adults who have developed post traumatic stress disorder from taking a dump. Reactions like this are why I routinely bring a chaperone with me when I do these exams – just to make sure that I don’t lose my wristwatch doing the exam, you know.

It’s not like doctors enjoy doing rectal exams. I can’t go home and say “Hey kids! I didn’t save anyone’s life, but guess what I did at work today!”
Oh, and clenching your butt cheeks together then arching your back in a seizure position doesn’t make things any easier. If you don’t want the exam, refuse it.

If you go to the emergency department to be evaluated for abdominal pain, vomiting blood, constipation, diarrhea, or abnormal stools, it’s nothing personal, but you’re going to need a rectal examination. It’s part of the job I do.

Expect it.

If you don’t complain about it, neither will I … well … at least not that much.

36 Responses to “Expect It”

  1. “could no longer stand in lines because he was afraid of what the people standing in line behind him might do.”
    the visual of someone standing in line anxiously looking at the people behind him at the grocery store fearful of getting wrestled to the ground and forced to have a rectal exam is just too funny.
    I can’t stop laughing.

  2. It never ceases to AMAZE me how uptight (pun intended) males are about the back door exam.

    Um hello?

    I’d love to see a man’s reaction to a speculum approaching any of their precious orifices. :P

  3. Katherine says:

    Seems like not enough patients know that they can refuse tests/examinations that they are too uncomfortable with. Enough people know that they can refuse major surgery, why can’t they extrapolate down from that?

  4. Abby says:

    I mean this respectfully and sincerely, and I hope it comes off that way: Is it possible that you could adapt your technique in some way that would make rectal exams less traumatic for patients?

    Obviously, you are a skilled and experienced clinician, and I have no doubt that your rectal exams are well-done from a procedural stand point. But it appears that more than one of your patients has felt like the exam was inappropriate, so maybe a better description of what you are going to be doing and why would help them relax? And why not tell them that it will be more comfortable for both of you if they don’t clench?

    I know that you probably don’t write this blog to get random critiques from anonymous readers, but I imagine that at this stage of your career, you don’t get a lot of feedback. On the off-chance that this advice is useful to reducing “traumatic” patient experiences, I thought it was worth writing. I hope you understand that I am not assuming you are doing a bad job, and I agree that the reaction of the patients you describe was a bit over the top, and not due to your exam skills.

    • DensityDuck says:

      Some people are so insanely homophobic that anything involving rectal insertion will be a problem. It’s like Ray Romano put it; “I was kind of afraid that it would hurt, but I was kind of MORE afraid that it WOULDN’T.”

      Indeed, that’s why the people in the story were being so weird about it. It was necessary for them to recast the situation as “violent assault” in their memory, so that when they thought about it they didn’t have to confront the notion that things-up-the-butt isn’t some horrible depraved disgusting thing that only perverts would ever do.

    • J says:

      WC,

      I agree, I have some tips for you on the rectal exam. I have started playing soft music, I turn the lights down, and often we scatter rose petals around the patient (still not sure if it is JCAHO compliant). I really try to make it much less traumatic and welcoming, especially for the GSW to the abdomen patients who just had a drug deal go bad.

      • WhiteCoat says:

        I’ll have to try this. Maybe my satisfaction scores will go up, too.
        On second thought, rose petals could cause an allergic reaction and could kill people. Also, people could slip on a wayward rose petal and fall on the floor hurting themselves. And the music might cause a patient not to hear a doctor’s instructions clearly. Definitely a patient danger. Low lights might cause us not to see blood pressure readings on the monitor accurately. Then we might give nitroprusside instead of dopamine which could kill someone, too. Yeah, JCAHO would definitely have issues with this.

      • Steve says:

        And how long would it take housekeeping to sweep up all those rose petals?

        Steve

    • WhiteCoat says:

      I absolutely write the blog to get critiques. I invite them. Airing opinions and hearing what other people have to say makes me a better doctor.
      It’s not like I walk into the room with my tongue hanging to the side, drool coming out of my mouth and a muffled evil laugh.
      I describe things fully before I do an exam and make sure that patients explicitly tell me that it’s alright that I proceed.
      If someone is clenching, I tell them I won’t be able to do the exam if they’re that uncomfortable with it.
      We’re put in a bad situation, though. If I do the exam and someone doesn’t like it, I get complaints. Doctors have even been sued for performing a rectal exam. If I don’t do the exam and I miss something, then I get complaints and get sued for not doing the exam.
      Sometimes we just can’t win.

  5. DefendUSA says:

    Love that story. And it’s so true. About the poops, I mean. :)

  6. Anonymous says:

    I had to schedule a clinic appointment to get one a couple of months ago. I didn’t care so much about the anal probing as much as I did about having to awkwardly drop pants in front of another (practically random) dude.

    “Wait I have to pay $20 for you to see *me* naked??”

  7. Sarah G says:

    What makes you think a BM couldn’t be traumatic? Maybe Fiber One gets these complaints, too.
    :-D

  8. ACZ says:

    Damn it “J”, you beat me to the punch! But here’s some additional ideas: candles, lots of ‘em. Some pleasant aromatherapy scent…oranges? I hear that’s calming. Speaking of calming, you could offer the probee a cup of Chamomile tea before the exam. Or maybe you just need to hold the patient afterward so they’ll know how much you really care and that you’re not just using them for your own gratification.

    As a veteran of many a DRE, I can tell you (as I’m sure everyone here already knows) THAT IT AIN’T NO BIG DEAL! JESUS CHRIST!!!

    Some years ago, I was talking with a friend about our GPs, and my friend said that he always chose female doctors (because of the DRE) because women had smaller fingers than men. I found this to be a rather odd reason for selecting a doctor, and I told him,”Hey,here’s a tip. If the doctor is stuffing their fist up your ass, they’re doing the exam wrong.”

  9. ACZ says:

    WC – “ASS-clay action-way awsuit-lay.”

    Very apropos. Not to mention funny!

  10. Katherine says:

    You know what sucks? Apparently the only reliable way to take a cat’s temperature is rectally. Try telling your CAT to relax >_< It is traumatic for me to watch; poor kitty meows :( At least people have the option to say no.

  11. Painless says:

    Hey WC.. don’t let Matt see you suggesting the “ass-clay action-way awsuit-lay”.. it might give him more idea’s than he already has. Then again, he’ll probably tell you that “ass-clay action-way awsuit-lay” is no more painfull than a thoughtfully performed rectal exam. Ohh wait.. I think I CAN see the similarities now.. Where’s Fyrdoc when you need him?

    • Matt says:

      Please, physicians love filing class actions. They’ve made billions. Probably asked for jury trials in them too.

    • Fyrdoc says:

      I’m right here. Matt just won’t answer me because my explanation to him that most (if not all) physicians regard lawyers in the same fashion that African American urban youth consider the police or the way most people feel about child molesters makes me a “psychopath” or “nut-job”.

      What he doesn’t want to realize, or what he does in the same way that he must know at a visceral level that he is wrong regarding medical malpractice, is that I’m neither crazy nor a psychopath. I’m honest and truthful (behind the anonymity of the web). A psychopath has a altered reality and can not identify where their altered universe ends and the real one begins.

      Matt just can’t fathom that my reality is reality. Physicians hate trial lawyers and honestly would leave them and their families without healthcare in the hopes that the experience would leave them with a new understanding of what their actions have done to restrict access to care for the rest of the population if that could be done in the current legal milieu. Unfortunately, it can’t.

      But hey, what do I know. I’m insane, doctors are all rich, medical malpractice is a wonderful means of quality control, defensive medicine either doesn’t exist or doesn’t cost anything, and doctors all respect attorneys as valuable partners in protecting the health and welfare of the public!

      • Matt says:

        Actually, I do fathom that you believe those things. I like to think most physicians don’t have your depth of hate, but I’m open to the possibility that it’s true.

        I also do appreciate the fact you believe that whatever your reality is that you think it is the “reality” shared by all. It’s that kind of misplaced egotism that reminds me just how off your rocker you are!

        One factual note though: there is no shortage of physicians except where there’s a shortage of wealthy people. Lawsuits, or the lack thereof, don’t change that. That’s the actual facts, whether you want to believe them or not.

        Carry on with the rantings! I’ll not interrupt you again.

  12. Steven says:

    Perhaps he was sexually abused at one time.

  13. SeaSpray says:

    Funny WC! So ..you do them up to your elbow? I guess you don the monster gloves then. ;)

    Post and comments funny. I appreciated the laugh. :)

    And the more serious comments insightful.

  14. MiniMedic says:

    For my yearly PAP, I get both a DRE and that damned speculum shoved up my ho-hah. Not a pleasant experience, but a few moments of pain are worth knowing that all is well in my woman regions.

    Men, cease your bitching before I hand you some Hershey’s.

  15. horsetech says:

    Somehow, I (female) am no longer interested in Tootsie Rolls after this thread.

    SeaSpray — maybe WC secretly wants to be a large animal vet? http://www.comstockequine.com/view_pic.php?id=193 (SFW)

  16. Of course formed stool is bigger than a normal sized finger, and it’s beside the point. They’re not talking about literally feeling like an arm is up their butts, they’re talking about the psych issue of having an area of their body they’ve been conditioned all their lives to regard as intensely private on display under bright lights before a small audience of strangers and then penetrated, not just with an inanimate medical tool but with someone’s – one of said strangers – HAND. I’ve heard many men describe prostate exams in exactly those terms (someone’s arm up their butts) and they mean how it makes them FEEL, EMOTIONALLY, and don’t know any other way to express it. You’re not just treating a de-personed body. If you want to be a good doctor, don’t succumb to the desensitization that too often takes hold in health care workers – nurses included – who poke/prod/stick/stab human beings all day long and forget what it feels like to be on the other end of the needle/cannula/catheter/speculum/scalpel/power saw. Hopefully the anaesthetic is working in the latter two cases, but sometimes it isn’t. And I’ve been there on THAT one.

  17. robbie says:

    I had to undergo a rectal/prostate exam for the military. The physician was about 128 years old and he literally shoved most of his hand into my ass. was in pain and later diagnosed with an anal fissure.

    Just because someone is an MD does not mean he/she knows what the heck they are doing/

  18. airman says:

    A while ago I had the misfortune of making an off-airport landing (crashing) a military liason aircraft onto a golf course, The impact was severe enough to totally destroy the plane, but I was surprizingly intact (head lacerations, broken wrist, a few burns, but nothing that was all that bad). I got transported to the nearest hospital ER and the doc on duty examined me; they cut off my clothes/flight suit but were nice about it. The doc told me that she needed to do a rectal exam, I asked it it was really necessary, she replied that it was, pulled the curtain around the bed and gave me a quick explanation. Before doing it, she reassured me that it wouldn’t hurt and asked me if it was o.k. to do it. As fast as I said that it was o.k. she was done, told the nurse that my “tone” or something was o.k. pulled the curtain back and I was off for more tests and scans. I got admitted and that doc came in to see me briefly and explained that I had a concussion and possible minor spinal injury, which turned out to be minor. She also told me that she was sorry about having to do the rectal exam, but that it was necessary. Having a doc who took a few seconds to let me know what was going on made all the difference.

  19. Banterings says:

    8th edition of ATLS has changed its position of the DRE recognizing the emotional trauma it inflicts.

    What if your patient was raped as a child and was too embarrassed to disclose this fact? Would you and all these indignant commenters still take the same position?

    What if the patient was a woman?

    Are you implying that the patient suffered no emotional trauma?

    This attitude marginalizes patients and tells them their feelings don’t matter.

    Aren’t physicians taught to “look” and “listen”??? The nurse told you that the first patient may have emotional trauma from the previous DRE you did or he may possibly may have PTSD from childhood rape (maybe?) But instead of asking, you made a joke about it.

    You have shown a complete disregard for your patient? What other subtle cues did you miss?

    What is really frightening is that no other commenters (who claim to be medical professionals), called you out on this.

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